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General NPI Number Information
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NPI Number | 1386035566
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Entity Type | Organization
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Legal Business Name | JIM GREEN COUNSELING, P.A.
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 47 MAIN STREET SUITE 230
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-941-1663
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Fax | 207-941-0077
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Provider Business Mailing Address
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Address Line | 47 MAIN STREET SUITE 230
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-941-1663
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Fax | 207-941-0077
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Authorized Official
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Title or Position | PROVIDER
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Name | MR. JAMES WILLIAM GREEN
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Credential | LCSW
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Telephone | 207-941-1663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LC5061
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License Number State | ME
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